Promoting Psychosocial Well-Being and Empowerment of Immigrant Women: A Systematic Review of Interventions

This systematic review (SLR), based on the PRISMA 2020 guidelines, aims to present a current overview of interventions aimed at promoting the psychosocial well-being and/or empowerment (PWE) of immigrant women in order to guide future projects. Data collection was performed in the SCOPUS and Web of Science databases, with studies published between 2012 and 20 March 2023 in English, Portuguese, and Spanish. Inclusion and exclusion criteria were based on the PICO guidelines: (P) immigrant women, (I) interventions to improve PWE, (C) comparison between the initial and final phases, and (O) evaluated results for PWE. Risk of bias was assessed, and most of the studies met more than 80% of the JBI bias criteria and had moderate quality on GRADE. Thirteen studies with 585 participants were included, mostly non-randomized, non-equivalent, and with an experimental-control group design. The main components of interventions were health education/psychoeducation, counseling, cognitive restructuring, and expressive therapies. A descriptive synthesis of qualitative and quantitative data was made to evaluate the results of the interventions in PWE. In the experimental studies, results assessed improvements mainly in mood and depression levels, and stress reduction. Empowerment components were less covered. Experimental groups performed better in almost all variables in the comparison with control groups. The strongest interventions were psychoeducation and cognitive restructuring techniques. The main limitations of the studies were the lack of quality of several studies, sample size and representativeness, language, and the possibility of response bias. Even taking this into account, this article makes an original contribution by advocating for evidence-based practice and offering significant implications for health professionals, policy makers, and researchers that work with the integrative health of immigrant women. This SLR is registered in PROPESRO Registration: CRD42023399683. PS is a research fellow of the Foundation for Science and Technology (FCT) of Portugal.


Introduction
Continuous advances in women's rights and achievements have been taking place, however, significant inequalities between men and women persist in several sectors, including the labor market, education, and the political environment. These inequalities can manifest themselves through reduced opportunities, pay gaps for equal or similar work, limited access to educational and cultural resources, unequal distribution of domestic and family care work, and denial of fundamental rights [1][2][3][4].
Immigrant women experience additional challenges regarding gender inequalities due to the intersection with other issues, such as ethnicity, culture, religion, beliefs, and the economic and social norms of their countries of birth [5]. These women handle these different challenges while they must also adjust to the new environment, often away from their reliable and relevant studies. On 25 March 2023, a snowball literature search was conducted to locate other eligible studies for our investigation. This approach is analogous to the "snowball sampling" used in primary research. In our search, we started with the identified body of articles in the databases. Then, the reference lists of these articles were analyzed to find additional studies. This method can help discover studies that the database search may have missed. Ultimately, it aims to reduce selection bias and identify a larger number of relevant studies on a topic.
After initial research and with the support of the Virtual Health Library platform, the search strategy included terms (and synonyms) related to immigration, women, intervention, psychosocial well-being, and empowerment, in English, Portuguese, and Spanish languages. Given the nuances of these terms in the different languages, Table 1 presents the translation for each of them. The decision to choose English, Portuguese, and Spanish languages for the studies included was guided by some considerations. These languages are considered among the most spoken worldwide and are particularly prevalent in countries with high rates of immigration. This fact increases the probability of finding studies on the topic. In addition, our team is proficient in these languages, which allowed us to interpret and analyze the studies more precisely, without the risk of misinterpretation due to language barriers.
The advanced search capabilities of the databases were utilized to ensure successful extraction of results. The keywords from the 3 languages were combined using search tools such as TS field (topic), Boolean operators AND, OR, and the wildcard character * (asterisk) in both databases. Articles that did not fulfill the inclusion criteria, as well as review articles and unpublished studies, were removed from the results. To ensure the efficiency of the search strategy, a validation process was conducted, resulting in the identification of four relevant studies. Appendix C provides more information on this process.

Criteria for Inclusion and Exclusion of Studies
For the inclusion and exclusion criteria we employed the PICO strategy: Participants: The population was composed of immigrant women over 18 years old living in a foreign country. Studies conducted exclusively with immigrant women under 18 or over 70 years old, pregnant, or postpartum women, and individuals with intellectual or physical disabilities and refugees were excluded.
Interventions: We included all interventions specifically designed to improve PWE. However, they were only included if they were clearly identified and protocolled. We classified interventions as "clearly identified" based on 2 criteria. (1) The intervention had to be explicitly stated and described in the study. This includes defining the type of intervention (e.g., counseling, psychoeducation). (2) The intervention had to be specifically targeted to improve PWE. Studies where the intervention was not the primary focus, or the goal was not PWE were not included. Interventions that essentially addressed physical conditions, substance abuse, parenting, or gender/domestic violence were also excluded. We classified interventions as "protocolized" when the program was implemented based on a pre-established structure (set of sessions, database with defined content, or completion of phases). The techniques used, duration, and frequency of the intervention were also to be presented. Therapies that did not have a defined plan were excluded from the study.
Comparisons: Results had to present a comparison between the initial and final phases of the intervention through a quantitative design (controlled trials, quasi-experimental design, and pre-test/post-test studies) or a mixed design (quantitative and qualitative methodology), if they evaluated the effectiveness of the intervention. Studies that did not present a comparison between the initial and final phases were excluded.
Outcomes: Results had to promote the PWE of the participants. Studies contained measures and analyses that made it possible to verify significant improvement in the empowerment and psychosocial well-being in the population assisted. Interventions whose measures and analyses were not clearly reported were excluded. We classified "measures and analyses clearly reported" when the measures and analysis tools were described in a precise and understandable way, allowing the analysis of our study variable (PWE) and the possibility of study replication. Studies that did not have at least one measure and data analysis tool clearly described were not included.

Article Selection Process
Data analysis was conducted using the Endnote Online. Results from databases were saved by title and abstract. Prior to assessing eligibility for inclusion, duplicate citations were removed and archived, first using the Endnote and then manually. Titles and abstracts were reviewed, and studies that were potentially relevant were included for full-text review. Full-text articles were reviewed. A PRISMA flow diagram was completed to describe the number of studies identified. A total of 3284 studies were initially retrieved. After removing duplicates using the Endnote (337) and manual screening (207), the titles and abstracts of 2740 articles were assessed for eligibility based on the PICO criteria, and 2631 were excluded. The main reasons for exclusion were that the target population was not immigrants, women, or they were children, pregnant women, or refugees; or the interventions were aimed at treating physical conditions such as cancer (mainly colon and breast), obesity, cardiovascular disease, diabetes, HIV, gynecological and obstetric issues, vaccination, parenting issues, or substance abuse. The remaining 109 articles were included for full-text analyses, and 60 were excluded. The reasons for exclusion at this stage were mainly because the population was mixed (male and female immigrants, whole families, immigrants, and non-immigrants), or the intervention did not aim for empowerment or psychosocial well-being, or this was not validated. Finally, 36 studies appeared to meet the inclusion criteria, but 20 were excluded because they only had one final evaluation measure or scored very low in the assessment of the risk of bias or did not clearly report the results. A total of 16 studies were excluded because they were implemented in very specific populations, such as caregivers, farm workers, or survivors of domestic violence. Finally, thirteen publications were included in this review. We searched the reference lists of included articles but did not identify any additional articles that met the inclusion criteria. Figure 1 presents the process of selection and inclusion of studies in each phase.
After the studies were selected, we extracted variables such as authors, year of publication, country of study, study design, sample cohort, intervention/program characteristics, data collection and analysis tools used, main results in the theme, and limitations. To prepare the data for synthesis, we categorized the collected variables in an Excel sheet and shared it among the authors. Table 2 presents a summary of the 13 included studies, including the N assigned to each study, author, year, country of study, study design, type of intervention and measures, study participants, and the effect of intervention on PWE. After the studies were selected, we extracted variables such as authors, year of publication, country of study, study design, sample cohort, intervention/program characteristics, data collection and analysis tools used, main results in the theme, and limitations. To prepare the data for synthesis, we categorized the collected variables in an Excel sheet and shared it among the authors. Table 2 presents a summary of the 13 included studies, including the N assigned to each study, author, year, country of study, study design, type of intervention and measures, study participants, and the effect of intervention on PWE.     The studies were published between 2012 and 2021, conducted in the USA (N = 6), Republic of Korea (N = 4), and Spain (N = 3). All studies had a pre/post intervention design (N = 13), and three had a follow-up after two [44], four [34], and six [38] weeks. Only one study [44] was a randomized and controlled experiment with a double-blind process. Twelve studies were quasi-experiments, divided into experimental and control group [34,35,37,39,40,44,45], experimental group in two [41] or four cohorts [36], or only a pre/post intervention experimental group [33,38,42,43]. Most studies were non-randomized (N = 7) and/or non-equivalent (N = 6). Only 3 were randomized [40,42,45].

Characteristics of Participants
A total of 584 immigrant women were evaluated and 433 received some type of intervention for the improvement of their psychosocial well-being and/or empowerment. A total of 151 participated in control groups. Sample sizes of the studies ranged from 11 to 75 participants. Seven studies reported that participants should be over 18 years old, and in three studies, over 21 years old. Some of the main inclusion criteria were depression (5), being married to a Korean or being in an international marriage (4), or needing some type of public or financial assistance (4). Women were mostly born in countries in Latin America (32%), Asia (21%), Europe (11%), and Morocco (16%).
We also examined the language used in the implementation of the intervention, studies [33,39,45] did not provide information on the language in which the programs were conducted. Studies [34,35,41,43] reported that the programs were implemented in the native language of the participants. In [36], the program was implemented in the native language of most of the participants, but it is unclear whether all women spoke the language of the program. Studies [37,38,40,42,44] indicated that the programs were conducted in the language of the country, and that the target population was able to communicate in that language. In [44], if the participants did not speak the language, a translator was present to provide translation services. Appendix D provides a description of the interventions in each study.

Instruments for Data Collection and Analysis
The most used instruments for data collection were the Patient Health Questionnaire (N = 6), followed by the Center for Epidemiologic Studies Depression (N = 4), the Final Questionnaire on Text Messages (N = 2), and the Perceived Stress Scale (N = 2). Other tests were used only once (N = 33). Descriptive analyses and sample identification were performed in all studies. The T-test was the most used test for data analyses (N = 8), followed by ANOVA [33,34,40,44], Wilcoxon [33,36,39], Mann-Whitney U test [34,39], and Fisher's exact test [40,44]. Other analyses were performed only once (N = 12). Semistructured interviews and qualitative analyses were conducted in 3 studies [41,42,45]. Only study [44] analyzed physiological data (saliva). [33] performed the most statistical analyses (N = 7), while [37] performed the fewest (N = 1). Appendix E provides a description of instruments for data collection and analysis in each study.

Quality of Studies
The risk of bias in the included studies was evaluated using the Joanna Briggs Institute (JBI) Appraisal Checklist Tools [46]. The JBI Appraisal Checklist for Randomized Controlled Trials, consisting of 13 items was used for the randomized controlled trial (Study [45]). For non-randomized studies, the JBI Appraisal Checklist for Quasi-Experimental Studies, consisting of 9 items was used (all other studies). In our investigation, only those studies that fulfilled over 50% of the established requirements were included. The choice of this cutoff by our team allowed us to find a balance between including the studies and ensuring an acceptable level of methodological quality and rigor in our analysis. Quasi-experimental studies had to meet 5 or more of the 9 criteria in the JBI Checklist for quasi-experimental studies. Experimental studies had to meet 7 or more of the 13 criteria in the JBI Checklist for experimental studies. Twelve studies were evaluated and met five [41], six [36,38], seven [33,35,37,42,43,45], eight [39], and nine [34,40] requirements of the criteria established by the quasi-experimental checklist (79%). Study [44] was evaluated using the experimental checklist and met 10 of the 13 requirements (77%). Table 3 shows the requirements for each study and their respective scores. Table 3. JBI Appraisal Checklist for risk of bias in quasi-experimental (9 items) and experimental (13 items) studies.
To evaluate the quality of the studies, we also assessed factors that could potentially interfere with the performance of the tests, such as the provision of payments in exchange for participation in the study. Our analysis revealed that four studies did not address this issue [39,40,43,45], while 3 studies explicitly stated that participation was entirely voluntary and no remuneration was provided [33,34,44]. Six studies offered some type of compensation, such as a gift or a gift card [35,38,41], expenses for phone and internet [36,37], or a financial compensation [42]. We also identified several limitations that may have impacted the reliability and validity of the findings. Some of the main limitations we identified were related to the sample size and/or representativeness [33,35,37,38,40,41,43,44], the possibility of response bias [34,38,[41][42][43][44], the lack of a control group [33,36,41,42], the study being conducted with convenience samples [33,41,43], language issues [34,40], and data collection being self-reported [40,42,43]. One study did not report limitations [39]. [45] only pointed out real-life economic constraints when implementing the program as a limitation. In seven studies, the risk of bias was unclear.
Finally, we conducted a Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the level of certainty related to the evidence and identify factors that could contribute to bias in the evidence. For this purpose, we defined a Likert scale ranging from 1 to 4 points, and the level of certainty of the evidence from each study was evaluated as high, moderate, low, or very low. Reasons for downgrading the evidence included limitations in study design, sample size and configuration, bias checklist score, quality of data collection and analysis, and reporting of results. Studies with very low quality were not included. Studies [33][34][35][36][37]40,42,43,45] were rated as moderate quality, while [38,39,41] were rated as low quality. Only study [44] was evaluated as high quality.

Data Analyses to Access PWE
Our analyses aimed to summarize the general effects of the implementation of the interventions on PWE and to verify the most suitable approaches for improving the PWE of immigrant women. To facilitate the identification of results, we defined 2 topics for each synthesis we would conduct. (1) For the results of the interventions on the PWE of immigrant women, studies were categorized into: (a) promotion of psychosocial wellbeing, (b) promotion of empowerment of women, and (c) promotion of both PWE. (2) For the evaluation of the strongest interventions affecting PWE in immigrant women, we performed a score compilation of the best findings for: (a) results in PWE, (b) quality of studies, and (c) descriptive synthesis of the studies. Using these codifications, we were able to identify the studies that met the eligibility criteria for each of our planned syntheses, as well as put them into the categories they best fit, creating a basis for our results.
Due to the heterogeneity in study designs and outcome measures, conducting a metaanalysis was not possible. Instead, we conducted a descriptive synthesis to summarize the PWE findings of the included studies. The synthesis involved a convergent analysis of the quantitative data, combining and interpreting the results to derive meaningful insights. When statistical aggregation was not possible, results were presented in a narrative format. Our analysis also included a thematic synthesis of the included studies that used qualitative analyses as part of their methodology (N = 2). Each qualitative result was reviewed, and the relevant data pertaining to our theme (PWE in immigrant women) were extracted. Subsequently, these data were coded and grouped into themes for presentation. After the categorization and analyses, the results were presented in a descriptive format.
The entire process of data collection, analysis, and risk of bias assessment was conducted in two stages: Stage 1 involved one reviewer (PS) who examined the studies and extracted the predefined variables. At Stage 2, a second reviewer (HP) verified the extracted data and supplemented them as necessary. Any discrepancies and uncertainties regarding the inclusion of a study, the data analysis process, or the bias categorization were resolved through discussion between the two reviewers (PS and HP). Whenever necessary, a third researcher and expert in the field was consulted for the final decision.

Results of the Interventions on PWE of Immigrant Women
In our research, we adopted a comprehensive understanding of psychosocial wellbeing, which encompasses various aspects such as mental health balance, quality of life, and social interactions. Empowerment refers to the dynamic process in which individuals or groups achieve and maintain autonomy, independence, and social participation. This implies, for example, being able to manage their own lives and make their own decisions. In this topic, we evaluated the effects of the interventions on these components across studies with experimental groups and studies with experimental and control groups.

Results of Experimental Studies on PWE of Immigrant Women
For studies conducted with only experimental groups, the main results on psychosocial well-being are observed through a significant difference post-intervention in the improvement of mood and depression levels [36,38,41,43]. There were also significant and positive differences in reducing stress [33,42,43], anxiety [38], and in post-traumatic stress [41]. In the evaluation of empowerment components, significant improvements were observed in increased self-esteem [33], self-efficacy, general empowerment, and safety-related empowerment [42], active coping, positive reframing, self-distraction, and planning [43]. In [43], these results were significantly associated with reduced stress and depressive symptoms. However, Ref. [33] did not show any significant improvements in sense of coherence and mental quality of life. In [36], only statistical differences occurred for experimental groups that showed moderate or high depression levels in the initial evaluation phase. In [38], the follow-up after 6 weeks did not show significant results. Three studies that evaluated variables related to social support did not present significant results after the intervention [33,41,43]. However, in [41], the qualitative analysis showed an improvement in the perception of social support. Except for [38,41], all these studies were rated with moderate quality in the GRADE evaluation and scored between five and seven points on the JBI Checklist for risk of bias for quasi-experimental studies.

Results of Experimental and Control Studies on PWE of Immigrant Women
Studies conducted with experimental and control groups showed significant differences after the intervention, with the experimental group scoring better in almost all variables. In terms of psychosocial well-being, there were improvements in mood and depression levels [34,35,37,40,44,45], anxiety [39,44], stress [45], acculturative stress [35,44], general health [35], loneliness [35,39], and a decrease in salivary cortisol [44]. Regarding the empowerment components, significant improvements were observed in health literacy [35], self-esteem [40], and life purpose [34]. In [34], these scores were maintained at both post-test and 4-week follow-up. However, there were no significant differences between the control and experimental groups in [39] scores, the overall effects of social problem solving [40], and salivary IgA [44]. Qualitative analyses revealed perceived improvements in loneliness, cognitive reconstruction, and financial assets. Except for [39], which rated as low quality, and [44], which rated as high quality, all of these studies were rated as moderate quality in the GRADE evaluation and scored between seven and nine points on the JBI Checklist for risk of bias for quasi-experimental studies. Ref. [44] scored 10 out of 13 points for the JBI checklist for experimental studies.

Strongest Interventions to PWE in Immigrant Women
Based on our findings, we assessed which interventions seemed to be the most effective for promoting PWE in immigrant women. We identified the techniques and approaches used in the included studies and selected those that had the strongest evidence base. The two interventions highlighted for their effectiveness and quality were psychoeducation and cognitive restructuring techniques.
Psychoeducation was implemented for different topics in six of the 13 included studies [33,35,[41][42][43]45]. In [33,35,45], topics such as acculturative stress, stress management, satisfactory relationships with husband, children and husband's family, mental health literacy, and utilization of mental health services were addressed. Ref. [42] provided individual feedback based on identified strengths and offered educational modules and sessions for stress reduction. In [41], psychoeducation was used as part of the content included in the behavioral activation program. In [43], sessions were provided related to the migration journey, adjustment to a new location, mental health, and social and family issues. These interventions were significantly effective in improving psychosocial wellbeing related to improvement of mood and depression levels, general health, in reducing stress, acculturative stress, post-traumatic stress, and loneliness. For the empowerment components, the benefits were related to increased self-esteem, self-efficacy, health literacy, general empowerment, safety-related empowerment, active coping, positive reframing, self-distraction, and planning. Except for [41], all of these studies were rated moderate in quality in the GRADE evaluation and scored seven on the JBI Checklist for risk of bias for quasi-experimental studies.
Cognitive restructuring techniques were used in five of the 13 studies [33,34,40,41,45]. Refs. [33,34] implemented sessions that involved producing a personal timeline, exploring relationships before and after migration, and exploring personal crises and attitudes toward those crises. Ref. [40] focused on cognitive reconstruction to promote a positive self-image, and develop personal strengths as well as problem solving skills. Ref. [41] adopted behavioral activation for the identification of problem behaviors and idleness and implemented interventions to increase activity and participation in pleasurable activities. Ref. [45], in turn, focused on developing psychological skills through cognitive strategies to identify symptoms of tension and their associated thoughts and feelings, in addition to strengthening social networks and building friendships. These interventions were significantly effective in improving psychosocial well-being in terms of reducing mood and depression levels, in reducing stress and post-traumatic stress, and loneliness. For the empowerment components, the benefits were related to increased self-esteem and life purpose. Furthermore, Ref. [34] implemented this technique and demonstrated better results on PWE measurements at the 4-week follow-up. Except for [41], all of these studies were rated with moderate quality in the GRADE evaluation and scored between seven and nine points on the JBI Checklist for risk of bias for quasi-experimental studies.
Nonetheless, although the qualitative analysis of [41] revealed an improvement in perceived social support, the studies that used psychoeducation and/or cognitive restructuring techniques for support issues and social problems [33,41,43] did not find significant quantitative results.

Effects of Interventions on PWE of Immigrant Women
All studies included in the review reported significant improvements in different aspects of psychosocial well-being. Immigrant women who participated in interventions showed improvements in mood and overall health, reduction of symptoms of depression, stress, acculturative stress, anxiety, PTSD, and loneliness. These effects were generally maintained when compared with the experimental and control groups, with a few exceptions. These findings are consistent with other SLRs that investigated interventions to improve the psychosocial well-being of immigrant people using psychosocial variables such as reduction of stress, depression, anxiety, suicidal ideation, and PTSD [47][48][49][50]. Furthermore, the therapies used in these studies were consistent with those that we found in our SLR, such as cognitive-behavioral techniques [47][48][49][50], counseling [49], psychoeducation [49,50], art therapy [49,50], mindfulness and relaxation [48,49], and group interpersonal theory [48,49].
In terms of the empowerment components, some interventions [33][34][35]40,42,43] that included counseling, health education/psychoeducation, and expressive and cognitive therapies delivered in groups and/or individually, showed positive effects in promoting immigrant women's empowerment. These results are presented through an increase in self-esteem, self-efficacy, general and safety-related empowerment, health literacy, and life purpose. In [43], psychoeducation and counseling resulted in significant improvements in active coping, positive reframing, self-distraction, and planning, which were significantly associated with reduced depressive symptoms. Improvements in self-esteem and selfefficacy can help immigrant women to feel more confident in their abilities and more prepared to face new challenges with positivity [51,52]. In addition, improved social problem-solving skills can help women to identify and handle problems and challenges that they may encounter through the immigration process [51]. Improvements in general and safety-related empowerment can increase women's sense of control and security in their lives [51,53]. These findings suggest that the interventions used in the included studies can lead to positive changes in the perception that individuals have of themselves and in their ability to cope with challenges in order to find a direction and a sense of purpose in their lives, a key component of women's empowerment [23,25], especially for those who are most vulnerable [54].
However, some studies did not find any significant results. Some reported improvements only in qualitative outcomes or found no significant differences between the experimental and control groups at pre-post-intervention or follow-up assessments. This variability can be attributed to several reasons, including differences in the quality of the interventions used, the samples studied, study designs, and outcome measures and analyses [55,56]. Additionally, three studies that assessed social support did not report significant post-intervention outcomes. Social support is a complex phenomenon and involves several stakeholders, such as community, family, friends, professionals, and others [57,58]. Therefore, preventing these variables from affecting the results becomes challenging.

Effectiveness of Psychoeducational and Cognitive Restructuring Interventions to PWE of Immigrant Women
We support psychoeducation and cognitive restructuring as the strongest techniques for promoting PWE in immigrant women based on their effectiveness in the included studies, as well as their methodological quality and beyond. Psychoeducation interventions sought to provide knowledge, skills, and resources to improve immigrant women's adaptation and well-being. Cognitive restructuring techniques were employed to help immigrant women challenge and change negative thought patterns, promoting a healthier and more adaptive perspective on themselves and their circumstances. Both interventions are accessible and easy to implement, which makes them appropriate for use in clinical and community settings. In addition, both are techniques that maintain an objectivity and standardization in their components, which allows for easier measurement, facilitating the evaluation of their effects on outcomes. Both approaches have demonstrated positive results in interventions for migrant and refugee people and their families in different contexts, such as: health treatment [59], reproductive health and mental health [60,61], detention [62], or undocumented [60] and empowerment for migrant groups [63,64]. In addition, we consulted the manual on supporting intervention for migrant women in reception centers [65] and the guide for psychological intervention with immigrants and refugees [66], which support as a main part of programs for intervention components based on techniques encompassing psychoeducation and cognitive restructuring. Finally, both approaches have found long-lasting effects in the PWE of different populations [67][68][69][70][71].
However, it is important to mention that none of the studies that evaluated questions about support and social problems did not have any significant results and this should be taken into consideration. This is important because the manual and the guidelines referred to the need to include the social context and the development of social skills [66]. Moreover, it is important to note that other methods and approaches were used in the studies included in this SLR, and their effects may be relevant for different populations and contexts. Consequently, the choice of interventions needs to consider the specific characteristics of immigrant women and their individual and collective needs. The toolkit "integrating migration into health interventions", by the International Organization for Migration, highlights the importance of promoting the inclusion of migrants of all genders in multisectoral coordination mechanisms and national health bodies. This involves supporting participation in the development of action plans for migrant health and ensuring evaluation of the implementation of these plans [72]. This is relevant to promote actions that really relate to the needs of the target population. Finally, there are also barriers specific to the immigrant population that impede the implementation of health care interventions, such as language barriers, belief systems, personality, stigma, discrimination, and others [66,72,73], that need to be considered.

Limitations and Future Directions
This review highlighted the lack of quality of several studies [74][75][76][77][78]. There was only one randomized controlled trial, which is a more consistent design to include in the RSL and enable meta-analyses, resulting in more reliable outcomes. Furthermore, the methodological quality was low or moderate for most of the included studies, as was the presence of possible selection and confounding biases [76]. Additionally, the heterogeneity in the methods and results of the included studies made it impossible to perform a meta-analysis, restricting the synthesis of results to a descriptive and qualitative interpretation [77]. The presence of single-arm studies was a limitation in terms of interpreting the possible causal inference of the results. Furthermore, the limited availability of studies on specific interventions to improve PWE in immigrant women may have contributed to the limited number of studies included in this review. These limitations make the generalization of our results to other populations and contexts difficult [74]. To address these limitations, future studies should use more randomized controlled trials with a high methodological quality to confirm the findings and establish a strong evidence base for effective interventions. In addition, efforts should be made to standardize data collection and analysis methods to improve comparability and meta-analysis of study results. Moreover, efforts to increase the number of studies on specific interventions to improve PWE in immigrant women should be made [74][75][76][77][78].
The sample size and geographic distribution of the studies included also present some limitations. In some studies, the sample size was very small (N = 11). In addition, the total sample size of evaluated immigrant women was only 585, and 454 received some type of intervention. This is a common limitation in research with specific populations, such as immigrant women, and may affect the generalizability of the results. Small sample sizes can also increase the risk of type II errors, where a true effect is not statistically detected even if it exists in the sample. Regarding geographical issues, the studies were conducted only in the United States, Republic of Korea, and Spain and the participants were born in Latin America, Asia, Europe, and Morocco. These limitations may have affected the generalizability of the results to other populations and contexts, as the results may have been influenced by specific characteristics of each country, the small sample size, or cultural, linguistic, and contextual factors that can vary among different populations.
Another limitation is related to the language used in the implementation of the interventions. In nine studies, there may have been problems regarding the participants' ability to understand the intervention. This is either because the program was implemented in the language of the country (N = 5), or because the studies did not fully (N = 3) or partially (N = 1) address the language in which the program was implemented. Finally, the criteria for inclusion and exclusion of participants varied across studies, and the characteristics and needs of the participants were not homogeneous. Furthermore, the allocation of the intervention and control groups in several cases was done by convenience and in a non-equivalent format, which might have affected the individual outcomes of the participants [55,56,74].
For future research, it is essential to conduct studies with larger and more representative samples, including immigrant women from different backgrounds and at different stages of their migration trajectories. In addition, it is recommended to address the language of the intervention more comprehensively, ensuring cultural and linguistic adaptation, as well as the availability of translation services whenever needed. It is also important to establish clear criteria for inclusion and exclusion of participants and to enable the homogeneity of samples. The use of randomized and equivalent allocation methods between intervention and control groups is also recommended. The inclusion of interventions that address the specific needs of immigrant women in different cultural and social contexts would be noteworthy. Finally, follow-up and longitudinal studies need to be implemented to ensure that the benefits gained are maintained in the long term [74][75][76][77][78].
In addition to these limitations, the present SLR also presented some limitations regarding the inclusion or exclusion of studies that should be considered when interpreting the results. In this sense, there were possible sources of bias in our research. The restriction of the selection of publications to English, Spanish, and Portuguese languages was a limitation, which may have restricted the inclusion of relevant studies. Similarly, the use of Scopus and Web of Science databases for data collection may have ignored studies indexed in other databases. In addition, gray literature or unpublished studies were not considered, which could have contributed to a more comprehensive review. In addition, even though we adopted clear inclusion and exclusion criteria, it is possible that we excluded relevant studies due to limitations in our search strategy or interpretation of the criteria. Another limitation relates to the complex and subjective construct of psychosocial well-being and empowerment, which made objective and comparable assessments across different studies more difficult. Despite efforts to make an unbiased selection, our interpretation of these concepts may have influenced the results of the review.
To address these limitations, future studies should consider adopting a more inclusive approach to language and publication sources, including studies in additional widely spoken languages such as Chinese, Hindi, Arabic, and Bengali. Furthermore, it would be beneficial to expand the search to include other databases, like PubMed and PsycINFO, as well as considering studies from the gray literature. In terms of inclusion and exclusion criteria, future studies would benefit from enhancing the search strategy and criteria to avoid excluding relevant studies. This can be achieved through a more comprehensive literature review, adjusting selection criteria, involving additional reviewers, conducting sensitivity analyses, and being transparent about the limitations. Additionally, to address the subjective and complex nature of PWE, researchers may consider using specific and standardized assessments or including specific variables as inclusion criteria that align with the PWE construct [74][75][76][77][78]. This approach can contribute to a more comprehensive understanding of the topic and help to mitigate the limitations associated with bias and the exclusion of relevant studies.

Originality and Implications
As far as we know, this is the first SLR that sought to evaluate the effects of interventions for PWE in immigrant women. Our review offers an innovative contribution by providing insights into four types of interventions (counseling, psychoeducation, cognitive therapies, expressive therapies) that have demonstrated efficacy in improving the psychological well-being of immigrant women. The results of the included studies showed significant improvements in various areas such as mood levels, depression, anxiety, stress, post-traumatic trauma, self-esteem, empowerment, and active coping skills. These findings are particularly innovative as they provide a comprehensive and holistic understanding of the effects of interventions on the psychological well-being of immigrant women, enabling the development of more comprehensive and effective interventions.
Furthermore, our findings may also contribute to the field, as we provide insights into effective and appropriate interventions for this population. Through the analysis of the included studies, we found that interventions based on psychoeducation and cognitive restructuring techniques stood out as the most effective. These innovative findings can contribute to the establishment of a solid evidence base that strengthens the clinical practice of health professionals and facilitates the development of future interventions. As these two approaches are structured and easy to implement, they can be incorporated into specific mental health and well-being programs and policies for this population, leading to positive and impactful outcomes.
Finally, our review identified gaps in the literature, which can highlight areas that require further investigation and guide future studies. The diversity of study designs and interventions highlighted in our review also emphasizes the importance of tailored approaches to address the individual needs of immigrant women. Each woman brings a unique migration experience and faces specific challenges in her adaptation process. Therefore, interventions that consider different cultural, linguistic, contextual, and socioeconomic experiences are essential to effectively address psychological well-being issues in this population. This information can guide future research, promoting a greater understanding of the most effective and appropriate interventions to improve the PWE of immigrant women and, consequently, contribute to the development of more inclusive and sensitive policies and practices tailored to their needs.

Conclusions
This SLR has provided promising evidence regarding the effectiveness of interventions aimed at improving PWE in immigrant women, despite variations in the results across studies. The experimental groups scored better in almost all variables after the interventions, even in comparison with the control group. The review also highlighted the limitations of the included studies, such as the lack of high-quality research, risk of bias, heterogeneity of methods and results, sample, and geographic locations. To address these limitations, interventions should be culturally sensitive and tailored to the specific needs of immigrant women. Furthermore, larger sample sizes and randomized controlled trials are necessary to establish the effectiveness of these interventions. These findings have important implications for health professionals and decision makers, providing guidelines for future interventions and informing health policies to consider the cultural and socioeconomic contexts of immigrant women. Finally, continued investment in research and interventions to promote PWE in immigrant women can lead to improved health and psychosocial well-being and enhance their engagement and empowerment in their new communities.
Author Contributions: Conceptualization, P.S. and H.P.; methodology, P.S.; software, P.S.; validation, H.P.; formal analysis, P.S.; investigation, P.S.; data curation, P.S.; writing-original draft preparation, P.S.; review and editing, H.P.; supervision, H.P.; project administration, P.S.; funding acquisition, P.S. All authors have read and agreed to the published version of the manuscript. Data Availability Statement: To request the dataset extracted for this SLR, send an email to Patricia Silva at pg.silva@ubi.pt. The data will be provided for academic or research purposes, and only if the ethics and privacy policies of both the institution and the research project are respected.

Conflicts of Interest:
The authors declare no conflict of interest. The funder FCT had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Appendix A. Checklist PRISMA 2020 for Abstracts
This appendix provides the checklist for reporting systematic reviews and metaanalyses in abstracts following the PRISMA 2020 guidelines. The checklist includes essential information that should be included in the abstract to ensure transparency and completeness in reporting. Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.

157-163 329-335
Data Collection Process 9 Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.
List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g., for all measures, time points, analyses) and, if not, the methods used to decide which results to collect.

308-319 10b
List and define all other variables for which data were sought (e.g., participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information.

200-204
Study Risk of Bias Assessment 11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently and, if applicable, details of automation tools used in the process. Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome. 298-304

Study Selection 16a
Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.

Synthesis of Results 16b
Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.

174-179
Study Characteristics 17 Cite each included study and present its characteristics. Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review.

Appendix C. Search Strategy in the Databases
This appendix outlines the search strategy used to retrieve relevant studies in the databases for our systematic review. The strategy was developed for the Web of Science and Scopus databases, in the English, Portuguese, and Spanish languages. Additionally, some common criteria for both databases are presented.

Database Language Search Strategy
Common Criteria YEAR OF PUBLICATION = 2010-2023 LANGUAGE = Portuguese, English, and Spanish TYPE OF THE STUDY = published paper, conference paper, editorial content * = The asterisk represents a sequence of characters that are unknown or that can be substituted or supplemented

Appendix D. Summary Table with Description of the Studies' Interventions Plan
Appendix D presents a summary that provides information about the intervention plan adopted in the studies included in the systematic review. The table contains details about the type of intervention plan, the program language used, and a brief description of the intervention plan in each study. In our SLR the studies were constructed based on sessions, contents, or implementation phases. Contents included photos, captions, and links to all videos and the resource-rich blog, including contact information and links to local and web-based resources, as well as hotlines to mental health services.
All sessions included each participant selecting five photos, doing a sandbox scene in silence, and recounting the emotions, physical sensations, memories, and ideas they felt while doing the sandbox scene. Then, two participants were put in pairs and one of them did a sand scene while the other became an observer of the work and reported back to the group. In the end everyone shared with the group.
[40] PHASES Language of the country.The participants were able to communicate in that language.
PHASE 1: Cognitive reconstruction, producing a positive self-image and developing your own strengths, understanding emotions and behaviors caused by cognitive distortion, and reinforcing rational thoughts. PHASE 2: Strengthening problem solving skills led participants to change their problem coping behavior through problem solving skill development. PHASE 3: Practice of integrating the contents learned through dramatization.
[41] CONTENTS Native language of the participants.
The content included behavioral activation (BA), a component of CBT for depression and PTSD. BA seeks to find problem behaviors and idleness and implements programs to help individuals become more active in their natural environment by connecting them to sources of reinforcement. It includes monitoring and evaluation of the enjoyment gained from participation in activities. Gradual attributions to involvement in enjoyable activities. Cognitive testing of programmed activities for possible obstacles.
[42] SESSIONS Language of the country.The participants were able to communicate in that language.
SESSION 1: Individual strengths-based telephone feedback based on survey responses and initial assessment. SUBSEQUENT SESSIONS: Self-directed online educational/psychoeducational modules and stress-reduction phone sessions facilitated by the research team. They addressed topics such as sexual-reproductive health, healthy relationships, immigration, HIV/STDs, career planning and financial management, family planning, and information on immigration visas or local service providers.
[43] SESSIONS Native language of the participants. T-test; Beta coefficient. [44] Quantitative: The acculturative stress index; The Center for Epidemiological Studies-Depression Scale (CES-D); The Beck Anxiety Inventory. Physiological analysis: Salivary cortisol and salivary; IgA levels.